💡 PROTON PUMP INHIBITORS (PPIs)

🧠 What Are PPIs?

• PPIs are the most potent acid-suppressing drugs available.

• They block the final step in acid production: the proton pump (H+, K+-ATPase) in parietal cells.

• They suppress ALL gastric acid—stimulated (meal/acid/histamine-induced) and basal/nighttime.

💊 PROTOTYPE: Omeprazole (Prilosec)

⚙ Mechanism of Action

• Irreversibly binds to the H+, K+-ATPase (proton pump).

• Prevents HCl from being secreted into the stomach lumen.

• Suppresses acid production from histamine, acetylcholine, and gastrin.

🔬 Pharmacokinetics

📌 USE

• PUD (duodenal & gastric ulcers)

  • Faster healing than H2RAs: ~2 weeks vs. 4 weeks

• GERD (esp. erosive esophagitis)

  • Relief in 1–2 weeks

  • Esophagitis heals in ~8 weeks

• Zollinger-Ellison syndrome

• H. pylori ulcers – used in triple therapy (PPI + 2–3 antibiotics + bismuth)

🧍‍♀ SPECIAL POPULATIONS

👵 Older Adults

• Tolerate PPIs well

• Preferred for GERD (need stronger acid suppression)

• Caution with long-term use (>1 year):

  • ↑ hip fracture risk (↓ Ca2+ absorption from achlorhydria)

  • ↑ dementia risk in some

• Use lowest effective dose for shortest time

🤰 Pregnancy & Breastfeeding

• OK during lactation – used successfully in neonates

🚰 Renal & Liver Impairment

• No dose adjustments typically needed

• Caution: Bioavailability ↑ in liver disease (↓ first-pass metabolism)

• Can ↑ LFTs transiently

🏥 Critically Ill

• Best choice for stress ulcer prophylaxis

• Available IV (esomeprazole, pantoprazole)

• Very effective and well tolerated

🚨 ADVERSE EFFECTS

Most Common:

• Nausea

• Diarrhea

• Headache

• Abdominal pain

Long-Term/High-Dose Risks:

• Hypocalcemia → fractures

• Hypomagnesemia → muscle cramps, seizures

• ↓ Vitamin B12 absorption → fatigue, weakness, neuro symptoms

Watch for:

• Chvostek & Trousseau signs (low calcium)

• Hyperreflexia/seizures (low magnesium)

⚠ CONTRAINDICATIONS

• Hypersensitivity to omeprazole

• Pregnancy (omeprazole specifically)

• Caution: CYP2C19 genetic variants → ↓ metabolism → ↑ drug levels/toxicity

🔄 DRUG INTERACTIONS (Important!!)

🔼 Increases levels of:

• Warfarin

• Phenytoin

• Benzodiazepines (e.g., diazepam)

• Clarithromycin (↑ omeprazole effects)

⬇ Decreases effectiveness of:

• Clopidogrel (↓ anti-platelet effect – ⚠ cardiac patients)

🧬 Metabolized by CYP450—especially CYP2C19
→ omeprazole and esomeprazole = highest interaction risk

💉 ADMINISTRATION GUIDELINES

• Take BEFORE meals (empty stomach)

• Do NOT chew or crush delayed-release capsules/tablets

• Two 20-mg ≠ One 40-mg → too much sodium bicarbonate in 2x20 mg doses!

• For patients with NG tubes or swallowing issues:

  • Sprinkle granules on applesauce (e.g., dexlansoprazole, lansoprazole)

  • Mix with water (esomeprazole)

• Pantoprazole IV:

  • Administer over 15 minutes

  • Use in-line filter

  • Flush line with dextrose, saline, or lactated Ringer's

🧪 THERAPEUTIC EFFECTS

• Decrease in:

  • Epigastric pain

  • Heartburn

• Ulcer healing in 2–8 weeks

• Monitor pH, symptom relief, and endoscopy/radiology if needed

🧠 ADVERSE EFFECT MONITORING

• GI: Nausea, diarrhea, vomiting

• CNS: Headache, dizziness

• Labs:

  • Magnesium

  • Calcium

  • B12

• Watch for:

  • Muscle cramps, hyperreflexia, seizures (low Mg)

  • Fatigue, neuropathy, tongue soreness (low B12)

  • Bone fractures (esp. hip/wrist/spine)

👩🏽‍⚕️ PATIENT TEACHING (Based on Box 37.1 & Clinical Case)

✅ Proper Administration

• Take before eating

• Swallow capsules/tablets whole

• Don’t use antacids within 1 hour

• Don’t take OTC PPI >14 days without provider

• Don’t substitute two 20 mg for one 40 mg

✅ Dietary Guidelines

• AVOID foods that trigger acid:

  • Spicy, fatty, fried foods

  • Chocolate

  • Coffee

  • Alcohol

  • Citrus/acidic juices

• Include:

  • Bland foods (bananas, rice, toast)

  • Lean protein

  • Low-fat dairy (if tolerated)

  • Calcium/magnesium-rich foods to help counter deficiencies

✅ Lifestyle Modifications

• Elevate head of bed

• Eat small meals

• Avoid lying down 1–2 hrs after eating

• Stop smoking

• Prevent constipation

🧠 OTHER PPIs — What Makes Them Different?

📚 CLINICAL TEACHING PLAN: MS. CARPENTER

📋 What to Teach

• Take omeprazole 40 mg once daily before food

• Don’t crush/chew – swallow whole

• Report abdominal pain, black stools, signs of bleeding

• Lifestyle changes (see above)

• Continue antacid & sucralfate as directed (spaced 1–2 hours apart)

🥗 Nutritional Teaching

• Avoid:

  • Fried, fatty, spicy foods

  • Chocolate, alcohol, caffeine

  • Tomato-based sauces, citrus

• Include:

  • Bland, low-acid foods

  • Bone health foods: leafy greens, almonds, dairy

  • Iron-rich & B12-rich foods: lean meat, spinach, eggs

✅ QUICK KEY TAKEAWAYS: PPIs

• PPIs = strongest acid reducers available

• Omeprazole = prototype, but high risk for drug interactions

• Take BEFORE meals, don’t crush tablets

• Used for PUD, GERD, Zollinger–Ellison, H. pylori ulcers

• Long-term use: watch for fractures, hypocalcemia, B12 & magnesium deficiency

• Preferred over H2RAs for severe/erosive GERD

• Pantoprazole = safest PPI for polypharmacy patients